1. Somatic Symptom and Dissociative Disorders
Chapter Six
Somatic Symptom and Dissociative Disorders

2. Somatic Symptom Disorders
Disorders that involve physical symptoms or anxiety over illness
Somatic symptom disorder (SSD)
Illness anxiety disorder
Conversion disorder (functional neurological symptoms disorder)
Factitious disorder

3. Somatic Symptom Disorders (cont’d.)

4. Somatic Symptom Disorder
Pattern of reporting distressing physical symptoms combined with extreme concern about health or fears of undiagnosed medical conditions
Symptoms must be present for at least six months
Symptoms not under voluntary or conscious control
Psychological in nature but often accompanied by medical conditions

5. Somatic Symptom Disorder (cont’d.)
SSD with predominantly somatic complaints:
Chronic complaints of specific bodily symptoms that have no physical basis
SSD with pain features:
Severe or lingering pain that appears to have no physical basis

6. Illness Anxiety Disorder
Previously called hypochondriasis
Persistent health anxiety and concern that one has an undetected physical illness with no or minimal somatic symptoms
Symptoms must be present for at least six months

7. Illness Anxiety Disorder (cont’d.)
Individuals with illness anxiety concerns:
Catastrophize
Overgeneralize
Display all-or-none thinking
Show selective attention
Cognitively based disorder

8. Illness Anxiety Disorder (cont’d.)

9. Conversion Disorder
Also known as functional neurological symptom disorder
Sensory or motor impairment suggestive of a neurological disorder, but with no underlying medical cause
Symptoms are not consciously being faked
Individual is not malingering, but rather believes there is a genuine problem

10. Conversion Disorder (cont’d.)
Most common symptoms:
Psychogenic movement
Originating from psychological cause
Disturbances of stance and walking
Sensory symptoms
Blindness, loss of voice, motor tics, and dizziness
Psychogenic seizures
Some symptoms are easily diagnosed, while others require extensive neurological and physical examination

11. Factitious Disorders Factitious disorder:
Symptoms of illness are deliberately induced, simulated, or exaggerated, with no apparent external incentive
Differs from malingering:
Faking a disorder to achieve some goal, such as an insurance settlement
In factitious disorder, the individual is usually unaware of the motivation for the behavior

12. Factitious Disorders (cont’d.)
Factitious disorder imposed on another:
Pattern of falsification or production of physical or psychological symptoms in another individual
Relatively new diagnostic category and as a result, little information is available on prevalence, age of onset, or familial pattern
Diagnosis of this condition is difficult

13. Etiology of Somatic Symptom Disorders
Figure 6-2 Multipath Model for Somatic Symptom Disorders The dimensions interact with one another and combine in different ways to result in a specific somatic symptom disorder.

14. Etiology of Somatic Symptom Disorders (cont’d.)
Biological dimensions:
Modest contribution of genetic factors
Biological predisposition hardwired into central nervous system can result in:
Hypervigilance or exaggerated focus on bodily sensation
Increased sensitivity to mild bodily changes
Tendency to react to somatic sensations with alarm
Repetitive activation of nervous system can lead to increased sensitivity of pain nerves

15. Etiology of Somatic Symptom Disorders (cont’d.)
Psychological dimension:
Role of reinforcement, modeling, catastrophic cognitions, or combination of these
Cognitive factors:
Somatic disorders may develop in predisposed individuals
Unrealistically interpret and overestimate dangerousness of bodily symptoms

16. Etiology of Somatic Symptom Disorders (cont’d.)
Social dimension:
Societal restrictions on women
Rejection or abuse from family members and feeling unloved
History of sexual abuse or rape
Parental modeling
Sociocultural dimension:
Cultural factors, including lower educational levels, ethnicity, and immigrant status

17. Treatment of Somatic Symptom Disorders
Biological:
Antidepressant medications such as SSRIs are used to treat somatic symptoms disorder ad illness anxiety disorder
Increased physical activity is recommended for conversion disorder

18. Treatment of Somatic Symptom Disorders (cont’d.)
Psychological:
Focus is understanding client’s view regarding problem
Demonstrate empathy
View disorders within social context
Cognitive-behavioral approaches
Correct cognitive distortions
Interoceptive exposure

19. Dissociative Disorders
Involves some sort of dissociation, or separation, of a part of a person’s consciousness, memory, or identity
Dissociative amnesia
Depersonalization/derealization disorder
Dissociative identity disorder
Relatively rare
No objective assessment:
Possibility of feigning

20. Dissociative Amnesia
Sudden partial or total loss of important personal information or recall of events due to psychological factors or stressors
May occur following a traumatic event or stressful circumstances
May also involve a fugue state

21. Dissociative Amnesia (cont’d.)
Localized amnesia:
Lack of memory for a specific event or events
Individuals may have selective amnesia or systematized amnesia
May occur after a repressed memory comes to light
Dissociative fugue:
Episode of complete loss of memory of one’s life and identity , unexpected travel to new location, or assumption of new identity
Recovery is often abrupt and complete

22. Depersonalization/Derealization Disorder
Characterized by feelings of unreality concerning the self and the environment
Depersonalization is the most common dissociative disorder
Diagnosis given only when feelings of unreality and detachment cause major impairment in social or occupational functioning

23. Dissociative Identity Disorder (DID)
Formerly called multiple personality disorder
Two or more relatively independent personality states appear to exist in one person, including experiences of possession
Diagnostic controversy

24. Etiology of Dissociative Disorders
Figure 6-4 Multipath Model of Dissociative Identity Disorder The dimensions interact with one another and combine in different ways to result in dissociative identity disorder.

25. Etiology of Dissociative Disorders (cont’d.)
Diagnosis depends on self-report, making it difficult to differentiate between genuine and faked cases
Two most influential models, post-traumatic and sociocognitive, are not sufficient to explain why only some develop disorders
Must look at vulnerabilities in biological, psychological, social, and sociocultural dimensions

26. Etiology of Dissociative Disorders (cont’d.)
Biological dimension:
Atypical brain functioning
Inhibited activity in hippocampus and hypometabolism in area of prefrontal cortex
Variations in brain activity when comparing different personalities
Difficult to interpret patterns of brain activity
Permanent structural changes in brain due to trauma may play a role
Reduction in amygdalar and hippocampal volumes

27. Etiology of Dissociative Disorders (cont’d.)
Psychological dimension:
Psychodynamic theory
Repression blocks unpleasant or traumatic events from consciousness
Protects individuals from painful memories or conflicts
DID results from severe childhood abuse

28. Etiology of Dissociative Disorders (cont’d.)
Psychological dimension: (cont’d.)
Four factors necessary for development of DID according to posttraumatic model (PTM)
Exposure to overwhelming childhood stress
Capacity to dissociate
Encapsulating or walling off the experience
Developing different memory systems
DID results from these factors if supportive environment is unavailable or if personality is not resilient

29. Etiology of Dissociative Disorders (cont’d.)
Figure 6-5 The Post-Traumatic Model of Dissociative Identity Disorder Note the importance of each of the factors in the development of dissociative identity disorder.
Source: Adapted from Kluft (1987); Loewenstein (1994).

30. Etiology of Dissociative Disorders (cont’d.)
Social and sociocultural dimension:
Sociocognitive model (SCM):
Displays of role enactments that have been created, legitimized, and maintained by social reinforcement
Patients learn about phenomenon and its characteristics from mass media, cues provided by therapist, personal experiences, and observation
Iatrogenic disorder: unintentionally produced by therapists actions and treatment strategies
High levels of hypnotizability and suggestibility

31. Treatment of Dissociative Disorders
Variety of treatments, including:
Supportive counseling
Hypnosis
Personality reconstruction
Currently no specific medication for dissociative disorders, but used to treat accompanying anxiety or depression

32. Treatment of Dissociative Disorders (cont’d.)
Dissociative amnesia and fugue:
Symptoms usually spontaneously end, but often associated with depression and/or stress
Treating dissociative disorders indirectly by alleviating depression and stress
Antidepressants or cognitive-behavioral therapy for depression
Stress-management techniques for stress

33. Treatment of Dissociative Disorders (cont’d.)
Depersonalization/derealization disorder:
Also subject to spontaneous remission, but at a much slower rate
Treatment focuses on alleviating feelings of depression, anxiety, or fear of going insane
Antidepressants and antianxiety medications

34. Treatment of Dissociative Disorders (cont’d.)
Dissociative identity disorder:
Major goal is use of trauma-based therapy to develop healthier ways of dealing with stressors
Hierarchical treatment approach involves:
Working on safety issues, stabilization, and symptom reduction
Reducing cognitive distortions
Identifying and working through traumatic memories
Stabilizing and learning to deal with stressors
Developing healthy relationships and practicing self-care

35. Treatment of Dissociative Disorders (cont’d.)
Dissociative identity disorder (cont’d.):
Treatment is not always successful
Greatest reduction in symptoms when individuals are able to integrate personalities

36. Treatment of Dissociative Disorders (cont’d.)
ABC Video: Robert Oxnam (Dissociative Identity Disorder)